The Glasgow Coma Scale consists of an assessment of: a. Pupil ...

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The Glasgow Coma Scale consists of an assessment of:
 
  a. Pupil reactivity and motor response.
  b. Eye opening and verbal and motor responses.
  c. Level of consciousness and verbal response.
  d. Intracranial pressure (ICP) and level of consciousness.

Question 2

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:
 
  a. Eye trauma. c. Severe brainstem damage.
  b. Neurosurgical emergency. d. Indication of brain death.

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Answer to Question 1

ANS: B
The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale.

Answer to Question 2

ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.

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